1) The document discusses the concept of angiosomes, which are the three-dimensional blocks of tissue fed by source arteries. It explores how well understanding angiosome territories can guide revascularization approaches. 2) There are different types of endovascular revascularization approaches that can be taken, including complete revascularization targeting all arteries, angiosome-guided targeting the artery directly feeding the problem area, and wound-related targeting the artery directly feeding the wound region. 3) For well-demarcated lesions, angiosome-guided or wound-related revascularization appears to provide good results, while complete revascularization is recommended for large wounds, deep infections, or when aggressive surgical treatment is planned

1. How much does the
angiosome concept really
matter?
Marco Manzi, MD
Interventional Radiology Unit
Foot & Ankle Clinic
Regional Center of Reference for the Treatment of Diabetic
Foot
Policlinico Abano, Abano Terme (PD)
ITALY

2. •Abbott Vascular: Consultant
•BARD/Clearstream: Consultant
•COOK: Consultant
•Covidien/EV3: Proctor
•Boston Scientific: Proctor
•Medtronic-Invatec: Consultant
Marco MANZI MD
DISCLOSURES

3. “Three-dimensional blocks of
tissue fed by source arteries”
Ian Taylor1
1 The vascular territories (angiosomes) of the body: Experimental studies and clinical
applications, Taylor, GI and Palmer JH. Br. J. Plast. Surg. 1990;43.
UNDERSTANDING ANGIOSOMES

4. Angiosome:
Anterior Tibial
Angiosome:
Peroneal Calcanear Branch
Angiosome:
Posterior Tibial
UNDERSTANDING ANGIOSOMES

5. The acute occlusion of one of the TIBIAL or FOOT arteries could
be immediately be compensated by the ANASTOMOTIC System
UNDERSTANDING ANGIOSOMES

6. UNDERSTANDING ANGIOSOMES

7. SHIFT TO A TERMINAL –LIKE
CIRCULATION
UNDERSTANDING ANGIOSOMES

8. Long-term results of direct and indirect endovascular
revascularization based on the angiosome concept in patients with
critical limb ischemia presenting with isolated below-the-knee lesions.
Osamu Iida, Yoshimitsu Soga, Keisuke Hirano, Daizo Kawasaki, Kenji
Suzuki, Yusuke Miyashita, Hiroto Terashi, Masaaki Uematsu
Kansai Rosai Hospital Cardiovascular Center, Hyogo, Japan.
iida.osa@gmail.com
Wound Healing Based on Revascularization of the Appropriate Angiosome
Neville RF, Attinger CE, Ann Vasc Surg 2009; 23(3):367-373
ANGIOSOMES RELEVANCE FOR TREATMENT

9. 0 I II III
A
Pre or postulcerative
lesion epithelialized
0%
Superficial
wound
0%
Wound
penetreting to
tendon or
capsule
0%
Wound
penetrating to
bone or joint
0%
B
Infection
12.5%
Infection
8.5%
Infection
28.6%
Infection
92%
C
Ischemia
25%
Ischemia
25%
Ischemia
25%
Ischemia
100%
D
Infection and
ischemia
50%
Infection and
ischemia
50%
Infection and
ischemia
100%
Infection and
ischemia
100%
Texas University Classification and prevalence of amputations
within each wound category
Armstrong D. et al: Validation of a diabetic wound
classification system. Diabetes Care Vol.21 n.5 855 (1998)
TUC 1C
TUC 2 C
TUC 3C
TUC 3D
ANGIOSOMES & Clinical Indications

10. Unuseful Forefoot Revascularization
Preserved Loop Lost Loop
ANGIOSOMES &Surgical Destiny

11. • “OLD” concept linked to Limb
Salvage
3. Single Vessel
• Direct Revascularization
(bypass or PTA) better than
Indirect
2. Angiosomes &
WRA
1. Complete • 1 vessel better than 0
• 2-3 vessels better than 1
• Tibials better than Peroneal
Kinds of Endorevascularization &ANGIOSOMES
R. Ferraresi, L.M.Palena, G.Mauri, M.Manzi
“Below the Ankle Peripheral Artery Disease” in
P.Lanzer, E.J.Topol - Panvascular Medicine- 2014 Ed.

12. ANGIOSOME GUIDED?

13. Baseline and Intervention

14. Angio and Clinical Results

15. ANGIOSOME GUIDED ?

16. Incomplete Revascularization Sample

17. Clinical Results

18. Indicated in patients with deep
infections, that involve more than one
angiosome.
Patients scheduled for forefoot
amputations (trasmetatarsal, Lisfranc or
Chopart)
COMPLETE is BETTER than ANGIOSOME GUIDED

19. Wound Related Revasc
Revascularization of the artery
directly feeding the wound
region.
Indicated in ulcers involving
only one angiosome.
Patients scheduled for
forefoot amputation can not
be treated following the
angiosome concept.
ANGIOSOME GUIDED

20. Revascularization Pattern Samples
WRA : Arterial Lesion clearly Related to a well demarcated foot
wound

21. Indirect ?
Was demonstrated that the restoration of the blood flow to the
ulcer through the collaterals provide good results in terms of
healing and limb salvage. (Varela et al. Vasc Endovasc Surg 2010; 44:654-660)
Revascularization Pattern Samples

22. 52 year-old man: diabetes; CLI (TcPO2 = 1 mmHg); TUC - 3C; forefoot gangrene
ANGIOSOME GUIDED ?

23. Baseline Angiography 1.11.2011

24. AVF
Acute Results

25. Clinical Results

26. CONCLUSIONS 1
• Angiosome guided / WR
revascularization does matter in
anatomically well demarcated
lesions;
• Should be always related to the
scheduled surgical option;

27. CONCLUSIONS 2
• Complete revascularization is
reccomended for huge wounds
and deep infections or scheduled
aggressive surgical treatment;
• More Studies are needed on the
potential relationship between
Angiosome guided/WR
revascularization and time of
healing

28. THANK YOU FOR YOUR ATTENTION